{"id":"F2021L01444","name":"Private Health Insurance (Prostheses) Rules (No. 3) 2021","slug":"private-health-insurance-prostheses-rules-no-3-2021","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"repealed","isInForce":false,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":102134,"registerId":"commonwealth-F2021L01444-current","compilationNumber":null,"startDate":"2026-04-03","status":"Repealed","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"Part 1","sectionType":"part","heading":"Preliminary","content":"## Part 1—Preliminary\n\n#### 1 Name\n\n This instrument is the Private Health Insurance (Prostheses) Rules (No. 3) 2021.\n\n#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

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Date/Details

1. The whole of this instrument

1 November 2021

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.\n\n#### 3 Authority\n\n This instrument is made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.\n\n#### 4 Repeal\n\n The Private Health Insurance (Prostheses) Rules (No.2) 2021 is repealed.\n\n#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) complying health insurance policy;\n (b) hospital-substitute treatment;\n (c) hospital treatment; and\n (d) medicare benefit.\n In this instrument:\n\nAct means the Private Health Insurance Act 2007.\n\ncardiac home/remote monitoring system includes a component of a cardiac home/remote monitoring system.\n\ncertified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\ncertified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\nconsultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\ndefault minimum benefit has the meaning given by subrule 9(5).\n\ngap permitted prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.\n\nimplantable cardiac event recorder includes a component of an implantable cardiac event recorder.\n\ninsulin infusion pump includes a component of an insulin infusion pump.\n\nlisted prosthesis means a kind of prosthesis listed in Schedule 1 to these Rules.\n\nlisting application has the same meaning as in subsection 72-10(6) of the Act.\n\nlisting criteria has the same meaning as in subsection 72-10(6) of the Act.\n\nNational Law means:\n\n(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or\n\n(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 (WA) that corresponds to the Health Practitioner Regulation National Law.\n\nno gap prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.\n\nprivate hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a private hospital.\n\nprofessional attendance has the same meaning as in clause 1.2.4 of the general medical services table being the table prescribed under section 4 of the Health Insurance Act 1973.\n\nprofessional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\npublic hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.\n\nregistered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.\n\n> Note: The registration requirements for a registered podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules from time to time.\n\nRegulations means the Health Insurance (General Medical Services Table) Regulations 2021 made under section 4 of the Health Insurance Act 1973.\n\nSchedule 1 means Schedule 1 to these Rules.\n\nsum of default minimum benefits has the meaning given by subrule 9(5).\n\n## Part 2—Benefit requirements\n\n#### 6 Listing of, and benefits for, prostheses\n\nFor item 4 of the table in subsection 72-1(2) of the Act:\n\n (a) Schedule 1 lists the kinds of prostheses:\n (i) in relation to which the Minister has granted an application for listing under subsection 72-10(5) of the Act; or\n (ii) which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and\n\nNote: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.\n\n (aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 7; and\n (ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 8; and\n (b) rule 9 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis; and\n (c) rule 10 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis.\n\n#### 7 Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable\n\nFor the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:\n\n (a) the provision of a listed prosthesis which is associated with podiatric treatment by a registered podiatric surgeon.\n\nNote: Paragraph (c) of item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.\n\n#### 8 Conditions in relation to the provision of listed prostheses\n\nFor the purposes of paragraphs (c) and (d) of item 4 of the table in subsection \n72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:\n\n (a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in Schedule 1 under the listing for that kind of prosthesis, that requirement; and\n (b) in relation to a listed prosthesis that is an insulin infusion pump, also:\n (i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and\n (ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and\n (iii) the insulin infusion pump must be provided for the purpose of administering insulin.\n\nNote: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.\n\n#### 9 Benefits for prostheses provided as part of hospital treatment\n\n (1) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (1A)) provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (1A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit for the prosthesis are as follows:\n\n if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;\n if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n (3) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (3A)) provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in Schedule 1.\n (3A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit for the prosthesis is the lesser of:\n (i) the amount for that prosthesis calculated in accordance with subrule (3B); or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for the prosthesis calculated in accordance with subrule (3B).\n (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount:\n (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis;\n (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for catheter cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the amount calculated in accordance with subrule (3B) for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (4) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in Schedule 1.\n\nNote: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n (5) For the purposes of this Rule:\n\nthe default minimum benefit for a prosthesis is the amount for that prosthesis listed in the Column in Schedule 1 under the heading ‘Minimum Benefit’;\n\nthe sum of default minimum benefits for a procedure is the sum of the default minimum benefits for each irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated ablation catheter and intracardiac electrophysiology catheter used in that procedure.\n\n#### 10 Benefits for prostheses provided as part of hospital-substitute treatment\n\n (1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are both the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n\nNote 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10(3)(a) of the Act.\n\nNote 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n## Part 3—Other\n\n#### 11 Timing of applications to have a prosthesis listed\n\nAs a matter of normal administrative practice, applications made under subsection 72-10(2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in Schedule 1 the next time the Minister makes or varies the Private Health Insurance (Prostheses) Rules.\n\nNote 1: Under subsection 72-10(5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.\n\nNote 2: Under subsection 72-15(3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.\n\n#### 12 Minister may have regard to recommendations and advice\n\nIn making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.\n\n#### 13 Listing criteria for prostheses to be listed in Part C of Schedule 1\n\nFor a listing application to be granted to list a kind of prosthesis in Part C of Schedule 1, the listing criterion is that the kind of prosthesis is:\n\n (i) an insulin infusion pump;\n (ii) an implantable cardiac event recorder;\n (iii) a cardiac home/remote monitoring system;\n (iv) an irrigated cardiac ablation catheter;\n (v) a mapping catheter for catheter cardiac ablation;\n (vi) a patch for cardiac ablation;\n (vii) a monopolar device for surgical cardiac ablation;\n (viii) a bipolar device for surgical cardiac ablation;\n (ix) a system for surgical cardiac ablation;\n (x) a probe for surgical cardiac ablation;\n (xi) a non-irrigated cardiac ablation catheter; or\n (xii) an intracardiac electrophysiology catheter.\n\nNote 1: The power to make listing criteria is in subsection 72-10(6) of the Act.\n\nNote 2: Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.\n\nNote 3: Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.","sortOrder":0},{"sectionNumber":"1","sectionType":"section","heading":"Name","content":"#### 1 Name\n\n This instrument is the Private Health Insurance (Prostheses) Rules (No. 3) 2021.","sortOrder":1},{"sectionNumber":"2","sectionType":"section","heading":"Commencement","content":"#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

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Commencement

Date/Details

1. The whole of this instrument

1 November 2021

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.","sortOrder":2},{"sectionNumber":"3","sectionType":"section","heading":"Authority","content":"#### 3 Authority\n\n This instrument is made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.","sortOrder":3},{"sectionNumber":"4","sectionType":"section","heading":"Repeal","content":"#### 4 Repeal\n\n The Private Health Insurance (Prostheses) Rules (No.2) 2021 is repealed.","sortOrder":4},{"sectionNumber":"5","sectionType":"section","heading":"Definitions","content":"#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) complying health insurance policy;\n (b) hospital-substitute treatment;\n (c) hospital treatment; and\n (d) medicare benefit.\n In this instrument:\n\nAct means the Private Health Insurance Act 2007.\n\ncardiac home/remote monitoring system includes a component of a cardiac home/remote monitoring system.\n\ncertified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\ncertified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\nconsultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\ndefault minimum benefit has the meaning given by subrule 9(5).\n\ngap permitted prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.\n\nimplantable cardiac event recorder includes a component of an implantable cardiac event recorder.\n\ninsulin infusion pump includes a component of an insulin infusion pump.\n\nlisted prosthesis means a kind of prosthesis listed in Schedule 1 to these Rules.\n\nlisting application has the same meaning as in subsection 72-10(6) of the Act.\n\nlisting criteria has the same meaning as in subsection 72-10(6) of the Act.\n\nNational Law means:\n\n(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or\n\n(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 (WA) that corresponds to the Health Practitioner Regulation National Law.\n\nno gap prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.\n\nprivate hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a private hospital.\n\nprofessional attendance has the same meaning as in clause 1.2.4 of the general medical services table being the table prescribed under section 4 of the Health Insurance Act 1973.\n\nprofessional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\npublic hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.\n\nregistered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.\n\n> Note: The registration requirements for a registered podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules from time to time.\n\nRegulations means the Health Insurance (General Medical Services Table) Regulations 2021 made under section 4 of the Health Insurance Act 1973.\n\nSchedule 1 means Schedule 1 to these Rules.\n\nsum of default minimum benefits has the meaning given by subrule 9(5).","sortOrder":5},{"sectionNumber":"Part 2","sectionType":"part","heading":"Benefit requirements","content":"## Part 1—Preliminary\n\n#### 1 Name\n\n This instrument is the Private Health Insurance (Prostheses) Rules (No. 3) 2021.\n\n#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

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Date/Details

1. The whole of this instrument

1 November 2021

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.\n\n#### 3 Authority\n\n This instrument is made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.\n\n#### 4 Repeal\n\n The Private Health Insurance (Prostheses) Rules (No.2) 2021 is repealed.\n\n#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) complying health insurance policy;\n (b) hospital-substitute treatment;\n (c) hospital treatment; and\n (d) medicare benefit.\n In this instrument:\n\nAct means the Private Health Insurance Act 2007.\n\ncardiac home/remote monitoring system includes a component of a cardiac home/remote monitoring system.\n\ncertified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\ncertified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\nconsultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\ndefault minimum benefit has the meaning given by subrule 9(5).\n\ngap permitted prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.\n\nimplantable cardiac event recorder includes a component of an implantable cardiac event recorder.\n\ninsulin infusion pump includes a component of an insulin infusion pump.\n\nlisted prosthesis means a kind of prosthesis listed in Schedule 1 to these Rules.\n\nlisting application has the same meaning as in subsection 72-10(6) of the Act.\n\nlisting criteria has the same meaning as in subsection 72-10(6) of the Act.\n\nNational Law means:\n\n(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or\n\n(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 (WA) that corresponds to the Health Practitioner Regulation National Law.\n\nno gap prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.\n\nprivate hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a private hospital.\n\nprofessional attendance has the same meaning as in clause 1.2.4 of the general medical services table being the table prescribed under section 4 of the Health Insurance Act 1973.\n\nprofessional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\npublic hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.\n\nregistered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.\n\n> Note: The registration requirements for a registered podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules from time to time.\n\nRegulations means the Health Insurance (General Medical Services Table) Regulations 2021 made under section 4 of the Health Insurance Act 1973.\n\nSchedule 1 means Schedule 1 to these Rules.\n\nsum of default minimum benefits has the meaning given by subrule 9(5).\n\n## Part 2—Benefit requirements\n\n#### 6 Listing of, and benefits for, prostheses\n\nFor item 4 of the table in subsection 72-1(2) of the Act:\n\n (a) Schedule 1 lists the kinds of prostheses:\n (i) in relation to which the Minister has granted an application for listing under subsection 72-10(5) of the Act; or\n (ii) which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and\n\nNote: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.\n\n (aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 7; and\n (ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 8; and\n (b) rule 9 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis; and\n (c) rule 10 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis.\n\n#### 7 Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable\n\nFor the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:\n\n (a) the provision of a listed prosthesis which is associated with podiatric treatment by a registered podiatric surgeon.\n\nNote: Paragraph (c) of item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.\n\n#### 8 Conditions in relation to the provision of listed prostheses\n\nFor the purposes of paragraphs (c) and (d) of item 4 of the table in subsection \n72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:\n\n (a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in Schedule 1 under the listing for that kind of prosthesis, that requirement; and\n (b) in relation to a listed prosthesis that is an insulin infusion pump, also:\n (i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and\n (ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and\n (iii) the insulin infusion pump must be provided for the purpose of administering insulin.\n\nNote: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.\n\n#### 9 Benefits for prostheses provided as part of hospital treatment\n\n (1) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (1A)) provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (1A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit for the prosthesis are as follows:\n\n if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;\n if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n (3) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (3A)) provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in Schedule 1.\n (3A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit for the prosthesis is the lesser of:\n (i) the amount for that prosthesis calculated in accordance with subrule (3B); or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for the prosthesis calculated in accordance with subrule (3B).\n (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount:\n (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis;\n (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for catheter cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the amount calculated in accordance with subrule (3B) for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (4) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in Schedule 1.\n\nNote: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n (5) For the purposes of this Rule:\n\nthe default minimum benefit for a prosthesis is the amount for that prosthesis listed in the Column in Schedule 1 under the heading ‘Minimum Benefit’;\n\nthe sum of default minimum benefits for a procedure is the sum of the default minimum benefits for each irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated ablation catheter and intracardiac electrophysiology catheter used in that procedure.\n\n#### 10 Benefits for prostheses provided as part of hospital-substitute treatment\n\n (1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are both the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n\nNote 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10(3)(a) of the Act.\n\nNote 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n## Part 3—Other\n\n#### 11 Timing of applications to have a prosthesis listed\n\nAs a matter of normal administrative practice, applications made under subsection 72-10(2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in Schedule 1 the next time the Minister makes or varies the Private Health Insurance (Prostheses) Rules.\n\nNote 1: Under subsection 72-10(5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.\n\nNote 2: Under subsection 72-15(3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.\n\n#### 12 Minister may have regard to recommendations and advice\n\nIn making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.\n\n#### 13 Listing criteria for prostheses to be listed in Part C of Schedule 1\n\nFor a listing application to be granted to list a kind of prosthesis in Part C of Schedule 1, the listing criterion is that the kind of prosthesis is:\n\n (i) an insulin infusion pump;\n (ii) an implantable cardiac event recorder;\n (iii) a cardiac home/remote monitoring system;\n (iv) an irrigated cardiac ablation catheter;\n (v) a mapping catheter for catheter cardiac ablation;\n (vi) a patch for cardiac ablation;\n (vii) a monopolar device for surgical cardiac ablation;\n (viii) a bipolar device for surgical cardiac ablation;\n (ix) a system for surgical cardiac ablation;\n (x) a probe for surgical cardiac ablation;\n (xi) a non-irrigated cardiac ablation catheter; or\n (xii) an intracardiac electrophysiology catheter.\n\nNote 1: The power to make listing criteria is in subsection 72-10(6) of the Act.\n\nNote 2: Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.\n\nNote 3: Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.","sortOrder":6},{"sectionNumber":"6","sectionType":"section","heading":"Listing of, and benefits for, prostheses","content":"#### 6 Listing of, and benefits for, prostheses\n\nFor item 4 of the table in subsection 72-1(2) of the Act:\n\n (a) Schedule 1 lists the kinds of prostheses:\n (i) in relation to which the Minister has granted an application for listing under subsection 72-10(5) of the Act; or\n (ii) which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and\n\nNote: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.\n\n (aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 7; and\n (ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 8; and\n (b) rule 9 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis; and\n (c) rule 10 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis.","sortOrder":7},{"sectionNumber":"7","sectionType":"section","heading":"Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable","content":"#### 7 Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable\n\nFor the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:\n\n (a) the provision of a listed prosthesis which is associated with podiatric treatment by a registered podiatric surgeon.\n\nNote: Paragraph (c) of item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.","sortOrder":8},{"sectionNumber":"8","sectionType":"section","heading":"Conditions in relation to the provision of listed prostheses","content":"#### 8 Conditions in relation to the provision of listed prostheses\n\nFor the purposes of paragraphs (c) and (d) of item 4 of the table in subsection \n72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:\n\n (a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in Schedule 1 under the listing for that kind of prosthesis, that requirement; and\n (b) in relation to a listed prosthesis that is an insulin infusion pump, also:\n (i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and\n (ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and\n (iii) the insulin infusion pump must be provided for the purpose of administering insulin.\n\nNote: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.","sortOrder":9},{"sectionNumber":"9","sectionType":"section","heading":"Benefits for prostheses provided as part of hospital treatment","content":"#### 9 Benefits for prostheses provided as part of hospital treatment\n\n (1) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (1A)) provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (1A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit for the prosthesis are as follows:\n\n if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;\n if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n (3) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (3A)) provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in Schedule 1.\n (3A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit for the prosthesis is the lesser of:\n (i) the amount for that prosthesis calculated in accordance with subrule (3B); or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for the prosthesis calculated in accordance with subrule (3B).\n (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount:\n (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis;\n (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for catheter cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the amount calculated in accordance with subrule (3B) for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (4) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in Schedule 1.\n\nNote: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n (5) For the purposes of this Rule:\n\nthe default minimum benefit for a prosthesis is the amount for that prosthesis listed in the Column in Schedule 1 under the heading ‘Minimum Benefit’;\n\nthe sum of default minimum benefits for a procedure is the sum of the default minimum benefits for each irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated ablation catheter and intracardiac electrophysiology catheter used in that procedure.","sortOrder":10},{"sectionNumber":"10","sectionType":"section","heading":"Benefits for prostheses provided as part of hospital-substitute treatment","content":"#### 10 Benefits for prostheses provided as part of hospital-substitute treatment\n\n (1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are both the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n\nNote 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10(3)(a) of the Act.\n\nNote 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.","sortOrder":11},{"sectionNumber":"Part 3","sectionType":"part","heading":"Other","content":"## Part 1—Preliminary\n\n#### 1 Name\n\n This instrument is the Private Health Insurance (Prostheses) Rules (No. 3) 2021.\n\n#### 2 Commencement\n\n (1) Each provision of this instrument specified in column 1 of the table commences, or is taken to have commenced, in accordance with column 2 of the table. Any other statement in column 2 has effect according to its terms.\n\n```html\n

Commencement information

Column 1

Column 2

Column 3

Provisions

Commencement

Date/Details

1. The whole of this instrument

1 November 2021

\n```\n\n> Note: This table relates only to the provisions of this instrument as originally made. It will not be amended to deal with any later amendments of this instrument.\n\n (2) Any information in column 3 of the table is not part of this instrument. Information may be inserted in this column, or information in it may be edited, in any published version of this instrument.\n\n#### 3 Authority\n\n This instrument is made under item 4 of the table in section 333-20 of the Private Health Insurance Act 2007.\n\n#### 4 Repeal\n\n The Private Health Insurance (Prostheses) Rules (No.2) 2021 is repealed.\n\n#### 5 Definitions\n\n> Note: A number of expressions used in this instrument are defined in the Act, including the following:\n\n (a) complying health insurance policy;\n (b) hospital-substitute treatment;\n (c) hospital treatment; and\n (d) medicare benefit.\n In this instrument:\n\nAct means the Private Health Insurance Act 2007.\n\ncardiac home/remote monitoring system includes a component of a cardiac home/remote monitoring system.\n\ncertified overnight Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\ncertified Type C procedure has the same meaning as in rule 3 of the Private Health Insurance (Benefit Requirements) Rules 2011.\n\nconsultant physician has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\ndefault minimum benefit has the meaning given by subrule 9(5).\n\ngap permitted prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and a different amount is set out in the column under the heading 'Maximum Benefit'.\n\nimplantable cardiac event recorder includes a component of an implantable cardiac event recorder.\n\ninsulin infusion pump includes a component of an insulin infusion pump.\n\nlisted prosthesis means a kind of prosthesis listed in Schedule 1 to these Rules.\n\nlisting application has the same meaning as in subsection 72-10(6) of the Act.\n\nlisting criteria has the same meaning as in subsection 72-10(6) of the Act.\n\nNational Law means:\n\n(a) for a State or Territory other than Western Australia — the Health Practitioner Regulation National Law set out in the Schedule to the Health Practitioner Regulation National Law Act 2009 (Qld) as it applies (with or without modification) as law of the State or Territory; or\n\n(b) for Western Australia — the legislation enacted by the Health Practitioner Regulation National Law (WA) Act 2010 (WA) that corresponds to the Health Practitioner Regulation National Law.\n\nno gap prosthesis means a prosthesis of a kind listed in Schedule 1 where an amount is set out for that kind of prosthesis in the column under the heading 'Minimum Benefit' and no amount is set out in the column under the heading 'Maximum Benefit'.\n\nprivate hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a private hospital.\n\nprofessional attendance has the same meaning as in clause 1.2.4 of the general medical services table being the table prescribed under section 4 of the Health Insurance Act 1973.\n\nprofessional service has the same meaning as in subsection 3(1) of the Health Insurance Act 1973.\n\npublic hospital means a hospital in respect of which there is in force a statement under subsection 121-5(8) of the Act that the hospital is a public hospital.\n\nregistered podiatric surgeon means a podiatric surgeon who holds specialist registration in the specialty of podiatric surgery under the National Law.\n\n> Note: The registration requirements for a registered podiatrist for the purposes of these Rules are the same registration requirements for podiatric surgeons as set out in rule 8 of the Private Health Insurance (Accreditation) Rules from time to time.\n\nRegulations means the Health Insurance (General Medical Services Table) Regulations 2021 made under section 4 of the Health Insurance Act 1973.\n\nSchedule 1 means Schedule 1 to these Rules.\n\nsum of default minimum benefits has the meaning given by subrule 9(5).\n\n## Part 2—Benefit requirements\n\n#### 6 Listing of, and benefits for, prostheses\n\nFor item 4 of the table in subsection 72-1(2) of the Act:\n\n (a) Schedule 1 lists the kinds of prostheses:\n (i) in relation to which the Minister has granted an application for listing under subsection 72-10(5) of the Act; or\n (ii) which are listed in accordance with section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007; and\n\nNote: Section 12 of the Private Health Insurance (Transitional Provisions and Consequential Amendments) Act 2007 deals with the listing of a prosthesis that was a no gap prosthesis or a gap permitted prosthesis for the purposes of the National Health Act 1953 immediately before the commencement of the Act.\n\n (aa) circumstances in which a listed prosthesis is provided for the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) are set out in rule 7; and\n (ab) conditions that must be satisfied in relation to the provision of a listed prosthesis for the purposes of paragraphs (c) and (d) of item 4 of the table in subsection 72-1(2) are set out in rule 8; and\n (b) rule 9 sets out the method for working out the minimum benefit and maximum benefit for hospital treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis; and\n (c) rule 10 sets out the method for working out the minimum benefit and maximum benefit for hospital-substitute treatment, covered under a complying health insurance policy, that is the provision of a listed prosthesis.\n\n#### 7 Circumstances in which a prosthesis is provided other than circumstances in which a medicare benefit is payable\n\nFor the purposes of paragraph (d) of item 4 of the table in subsection 72-1(2) of the Act, the following circumstances are set out:\n\n (a) the provision of a listed prosthesis which is associated with podiatric treatment by a registered podiatric surgeon.\n\nNote: Paragraph (c) of item 4 of subsection 72-1(2) deals with the provision of a listed prosthesis in circumstances in which a medicare benefit is payable.\n\n#### 8 Conditions in relation to the provision of listed prostheses\n\nFor the purposes of paragraphs (c) and (d) of item 4 of the table in subsection \n72-1(2) of the Act, conditions that must be satisfied in relation to the provision of a listed prosthesis in the circumstances covered by paragraph (c) or (d) of that item, as the case may be, are:\n\n (a) in relation to any kind of prosthesis where there is a statement of a requirement under the heading 'Condition' in Schedule 1 under the listing for that kind of prosthesis, that requirement; and\n (b) in relation to a listed prosthesis that is an insulin infusion pump, also:\n (i) the professional service associated with the provision of the insulin infusion pump must be a professional attendance by a consultant physician in the practice of his or her specialty; and\n (ii) the professional service must be provided as a certified Type C procedure or certified overnight Type C procedure; and\n (iii) the insulin infusion pump must be provided for the purpose of administering insulin.\n\nNote: Item 4 of the table in subsection 72-1(2) of the Act states other requirements in relation to benefits for the provision of prostheses that a policy that covers hospital treatment must meet. These requirements relate to benefits for hospital treatment and, if the policy covers hospital-substitute treatment, to the benefits of that coverage as well.\n\n#### 9 Benefits for prostheses provided as part of hospital treatment\n\n (1) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (1A)) provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit are each the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (1A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a private hospital, the minimum benefit and the maximum benefit for the prosthesis are as follows:\n\n if the sum of the default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the minimum benefit and the maximum benefit are each the default minimum benefit for the prosthesis;\n if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the minimum benefit and the maximum benefit are each to be calculated using the following method: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the minimum benefit and maximum benefit for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (2) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a private hospital:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n (3) For a no gap prosthesis (other than a no gap prosthesis referred to in subrule (3A)) provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading 'Minimum Benefit' in Schedule 1.\n (3A) For a no gap irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated cardiac ablation catheter, or intracardiac electrophysiology catheter, provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit for the prosthesis is the lesser of:\n (i) the amount for that prosthesis calculated in accordance with subrule (3B); or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for the prosthesis calculated in accordance with subrule (3B).\n (3B) The amount for a prosthesis calculated in accordance with this subrule is the following amount:\n (a) if the sum of default minimum benefits for the procedure in which the prosthesis was used is $6399 or less, the amount is the default minimum benefit for the prosthesis;\n (b) if the sum of default minimum benefits for the procedure in which the prosthesis was used is more than $6399, the amount is to be calculated as follows: divide the default minimum benefit for the prosthesis by the sum of the default minimum benefits for the procedure in which the prosthesis was used, and multiply the result by $6399.\n\n> Note: For example, if an irrigated cardiac ablation catheter, a mapping catheter for catheter cardiac ablation and a patch for cardiac ablation each listed in Schedule 1 are used in a relevant procedure in accordance with any conditions, and the default minimum benefit of the irrigated cardiac ablation catheter is X, the default minimum benefit of the mapping catheter for cardiac ablation is Y, and the default minimum benefit of the patch for cardiac ablation is Z, the sum of the default minimum benefits for the procedure is (X+Y+Z). If the sum of the default minimum benefits for the procedure (X+Y+Z) is more than $6399, the amount calculated in accordance with subrule (3B) for the irrigated cardiac ablation catheter is calculated by taking X, dividing it by (X+Y+Z), then multiplying the result by $6399.\n\n (4) For a gap permitted prosthesis provided as part of an episode of hospital treatment in a public hospital:\n (a) the minimum benefit is the lesser of the following amounts:\n (i) the amount for that prosthesis listed in the column under the heading ‘Minimum Benefit’ in Schedule 1; or\n (ii) the amount of the insured person’s liability to the public hospital for that prosthesis; and\n (b) the maximum benefit is the amount for that prosthesis listed in the column under the heading ‘Maximum Benefit’ in Schedule 1.\n\nNote: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n (5) For the purposes of this Rule:\n\nthe default minimum benefit for a prosthesis is the amount for that prosthesis listed in the Column in Schedule 1 under the heading ‘Minimum Benefit’;\n\nthe sum of default minimum benefits for a procedure is the sum of the default minimum benefits for each irrigated cardiac ablation catheter, mapping catheter for catheter cardiac ablation, patch for cardiac ablation, monopolar device for surgical cardiac ablation, bipolar device for surgical cardiac ablation, system for surgical cardiac ablation, probe for surgical cardiac ablation, non-irrigated ablation catheter and intracardiac electrophysiology catheter used in that procedure.\n\n#### 10 Benefits for prostheses provided as part of hospital-substitute treatment\n\n (1) For a no gap prosthesis provided as part of an episode of hospital-substitute treatment the minimum benefit and the maximum benefit are both the amount for that prosthesis listed in the column in Schedule 1 under the heading ‘Minimum Benefit’.\n (2) For a gap permitted prosthesis provided as part of an episode of hospital-substitute treatment:\n (a) the minimum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Minimum Benefit’; and\n (b) the maximum benefit is the amount for that prosthesis in the column in Schedule 1 under the heading ‘Maximum Benefit’.\n\nNote 1: Private health insurers cannot cover, as part of hospital-substitute treatment, a service for which medicare benefit is payable unless the service is specified in the Private Health Insurance (Health Insurance Business) Rules ―see paragraph 121-10(3)(a) of the Act.\n\nNote 2: Paragraphs (d) and (e) of subsection 72-10(5) of the Act deal with the fixing of minimum and maximum benefits when the Minister is making or varying the Private Health Insurance (Prostheses) Rules.\n\n## Part 3—Other\n\n#### 11 Timing of applications to have a prosthesis listed\n\nAs a matter of normal administrative practice, applications made under subsection 72-10(2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in Schedule 1 the next time the Minister makes or varies the Private Health Insurance (Prostheses) Rules.\n\nNote 1: Under subsection 72-10(5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.\n\nNote 2: Under subsection 72-15(3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.\n\n#### 12 Minister may have regard to recommendations and advice\n\nIn making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.\n\n#### 13 Listing criteria for prostheses to be listed in Part C of Schedule 1\n\nFor a listing application to be granted to list a kind of prosthesis in Part C of Schedule 1, the listing criterion is that the kind of prosthesis is:\n\n (i) an insulin infusion pump;\n (ii) an implantable cardiac event recorder;\n (iii) a cardiac home/remote monitoring system;\n (iv) an irrigated cardiac ablation catheter;\n (v) a mapping catheter for catheter cardiac ablation;\n (vi) a patch for cardiac ablation;\n (vii) a monopolar device for surgical cardiac ablation;\n (viii) a bipolar device for surgical cardiac ablation;\n (ix) a system for surgical cardiac ablation;\n (x) a probe for surgical cardiac ablation;\n (xi) a non-irrigated cardiac ablation catheter; or\n (xii) an intracardiac electrophysiology catheter.\n\nNote 1: The power to make listing criteria is in subsection 72-10(6) of the Act.\n\nNote 2: Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.\n\nNote 3: Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.","sortOrder":12},{"sectionNumber":"11","sectionType":"section","heading":"Timing of applications to have a prosthesis listed","content":"#### 11 Timing of applications to have a prosthesis listed\n\nAs a matter of normal administrative practice, applications made under subsection 72-10(2) of the Act will be considered after they have been received and, if the Minister decides to grant the application, the kind of prosthesis will be listed in Schedule 1 the next time the Minister makes or varies the Private Health Insurance (Prostheses) Rules.\n\nNote 1: Under subsection 72-10(5) of the Act the Minister must list the kind of prosthesis, set out the minimum benefit and, if the Minister considers it appropriate, the maximum benefit for the prosthesis in these Rules on the next occasion that the Minister makes or varies the Rules after he or she grants an application and the applicant has paid to the Commonwealth any initial listing fee within 14 days of being informed of the Minister's decision to grant the application.\n\nNote 2: Under subsection 72-15(3) of the Act, the Minister may remove a kind of prosthesis from the list in the Rules if the applicant fails to pay an ongoing listing fee.","sortOrder":13},{"sectionNumber":"12","sectionType":"section","heading":"Minister may have regard to recommendations and advice","content":"#### 12 Minister may have regard to recommendations and advice\n\nIn making the decision under subsection 72-10 of the Act, the Minister may have regard to a recommendation from the Prostheses List Advisory Committee.","sortOrder":14},{"sectionNumber":"13","sectionType":"section","heading":"Listing criteria for prostheses to be listed in Part C of Schedule 1","content":"#### 13 Listing criteria for prostheses to be listed in Part C of Schedule 1\n\nFor a listing application to be granted to list a kind of prosthesis in Part C of Schedule 1, the listing criterion is that the kind of prosthesis is:\n\n (i) an insulin infusion pump;\n (ii) an implantable cardiac event recorder;\n (iii) a cardiac home/remote monitoring system;\n (iv) an irrigated cardiac ablation catheter;\n (v) a mapping catheter for catheter cardiac ablation;\n (vi) a patch for cardiac ablation;\n (vii) a monopolar device for surgical cardiac ablation;\n (viii) a bipolar device for surgical cardiac ablation;\n (ix) a system for surgical cardiac ablation;\n (x) a probe for surgical cardiac ablation;\n (xi) a non-irrigated cardiac ablation catheter; or\n (xii) an intracardiac electrophysiology catheter.\n\nNote 1: The power to make listing criteria is in subsection 72-10(6) of the Act.\n\nNote 2: Under subsection 72-10(7) of the Act the Minister must not grant a listing application if any applicable listing criteria are not satisfied in relation to the application.\n\nNote 3: Under the Act the Minister may refuse to grant a listing application even if the listing criteria are satisfied. See Note to subsection 72-10(7) of the Act.","sortOrder":15}],"analysis":{"kimi_summary":{"_metrics":{"model":"kimi-k2.5","source":"moonshot-realtime","completionTokens":2024},"content_quality":"ok","complexity_score":6,"scope_assessment":{"changed":false,"description":"This instrument is a routine replacement (repealing the Private Health Insurance (Prostheses) Rules (No.2) 2021) that maintains the existing legislative framework for prostheses benefits. It does not expand beyond the established scope of regulating minimum and maximum benefits for prostheses provided under complying health insurance policies."},"complexity_factors":["18 defined terms, many imported by reference from other Acts including the Private Health Insurance Act 2007, Health Insurance Act 1973, and Health Practitioner Regulation National Law","Dual classification system requiring distinction between 'no gap' and 'gap permitted' prostheses with different benefit calculation rules","Location-specific conditional logic distinguishing between benefits payable for public hospital vs private hospital treatment","Mathematical pro-rata reduction formula for cardiac ablation devices exceeding the $6,399 threshold in rule 9(1A) and (3B)","Cross-references to at least 4 other legislative instruments including the Benefit Requirements Rules and Accreditation Rules","Specific qualifying conditions for high-cost items like insulin infusion pumps requiring certified Type C procedures"],"plain_english_summary":"This instrument sets rules for how private health insurers must cover prostheses used in hospital or hospital-substitute treatment via a maintained Prostheses List that distinguishes \"no gap\" items from \"gap permitted\" items (insurer minimums and possible patient out‑of‑pocket charges). It also sets different benefit calculations for private versus public hospitals and special rules for certain devices.\n\nNotable specifics include a $6,399 cap formula for some cardiac devices, conditions for items like insulin pumps and podiatric prostheses, and a process for adding new devices. It affects insured patients and device manufacturers."},"flash_summary":{"complexity_score":7,"scope_assessment":{"changed":false,"description":"The instrument implements the listing and benefit‑setting functions authorised by the Act (item 4 of the table in subsection 72‑1(2)) and repeals the prior Rules (rule 4). It does not itself state an expansion or contraction of the statutory scope; it sets device lists, payment amounts and administrative conditions consistent with the Act and the Act’s listing procedures (see rule 6 and rules 11–13)."},"complexity_factors":["Cross‑references to the Private Health Insurance Act 2007 and other instruments for definitions and authority (see rule 3; definitions in rule 5 and references to the Act and Regulations).","Dual categories of prostheses (no gap vs gap permitted) with different payment rules and the need to consult Schedule 1 for amounts and conditions (definitions and rules 9, 10, Schedule 1).","Different calculations for private‑hospital and public‑hospital settings, including a cap/allocation algorithm for listed cardiac ablation devices where the sum of default minimum benefits exceeds $6,399 (rules 9(1A), 9(3A)‑9(3B)).","Separate treatment for hospital treatment vs hospital‑substitute treatment with parallel but distinct benefit rules (rules 9 and 10).","Specific clinical/administrative conditions for some devices (eg insulin infusion pumps require a consultant physician attendance and certified Type C procedure — rule 8(b)).","Ministerial discretion and administrative procedures for listing, timing and fee‑based ongoing listing obligations (rules 6, 11, 12 and 13; notes referencing subsections 72‑10 and 72‑15 of the Act).","Reliance on Schedule 1 to determine monetary amounts and any device‑specific 'Condition' statements, which concentrates substantive detail outside the main rules (see rule 6 and rule 8(a)).","Repeal of the prior instrument and effect of commencement provisions, which can affect transitional or operational timing (rules 2 and 4)."],"plain_english_summary":"This instrument lists specific prosthetic devices that private health insurers must recognise and fixes the minimum (and in some cases maximum) insurer payments when those devices are provided in hospital or hospital‑substitute care. It also sets clinical and administrative conditions for cover, a formula that caps and allocates payments for certain cardiac ablation devices, and the process by which the Minister adds or removes devices.\n\nIt affects private insurers, hospitals (public and private), device suppliers and insured patients by determining insurer payment obligations, potential patient out‑of‑pocket gaps and the listing/compliance process."}},"importantCases":[],"_links":{"self":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021","history":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021/history","analysis":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021/analysis","conflicts":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021/conflicts","importantCases":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021/important-cases","documents":"/api/acts/private-health-insurance-prostheses-rules-no-3-2021/documents"}}